Combined primary subintimal and endoluminal angioplasty for ischaemic inferior-limb ulcers in diabetic patients: 5-year practice in a multidisciplinary 'diabetic-foot' service.

INTRODUCTION: This study aims to assess the patency, the clinical success and the limb-salvage rates of combined subintimal (SA) coupled to endoluminal angioplasty (EA) as the initial treatment of ischaemic inferior-limb ulcers in diabetic patients and to study the influence of other concurrent factors in the tissue-healing process. MATERIALS AND METHOD: Since September 2002 until December 2007, a consecutive series of 176 limbs with manifold ischaemic wounds in 161 diabetic patients were treated by associated multilevel angioplasties in a multidisciplinary 'diabetic-foot team' (a third-line diabetic-care institution integrating two departmental hospitals). There were 98 associated SA with EA procedures, 26 re-vascularisations by single SA technique and 52 others including selective multilevel EAs that were retrospectively reviewed. The mean follow-up period was 22.1 months (in the range of 1-50 months) by clinical and duplex evaluation (every 6 months). RESULTS: The initial technical success was noted in 149 limbs (84%). For the single or associated SA procedures, 102 of 124 procedures were successful (82%) and 145 of 150 of the miscellaneous EAs (96%) evinced an equally favourable outcome. The 27 initially failed endovascular procedures (22 SA and five EA) required 16 surgical re-vascularisation, eight adjuvant endovascular procedures besides three amputations. A total of 21 secondary and five tertiary angioplasties were equally necessary during the entire follow-up period of these patients. The 30-day survival rate was 99% (one patient died from myocardial infarction). In a intention-to-treat analysis, the cumulative primary and secondary patencies at 12, 24, 36 and 48 months were 62%, 45%, 41% and 38%, together with 80%, 69%, 66% and 66%, respectively. The aggregate clinical success rates at the same intervals were 86%, 77%, 70% and 69%, while the corresponding limb-salvage proportions showed 89%, 83%, 80% and 80%, respectively. The primary patency was negatively affected at 1 and 4 years by the length of the occluded segment (>10 cm) and the end-stage renal disease (ESRD) (p<0.0001). The limb-salvage rates were unfavourably influenced at the same periods by the extent of tissue defects (>3 cm), the ESRD and the presence of osteomyelitis. In addition, at 4 years, the age (>70 years), the accompanying peripheral neuropathy, the bedridden status and the presence of cardiac failure (left ventricular ejection fraction (LVEF)<30%) appeared equally as negative predictors (p<0.0001) for wound healing and limb rescue. CONCLUSION: Primary angioplasty represents a low aggressive and efficacious method to improve the healing process in diabetic ischaemic ulcers. However, beyond appropriate re-vascularisation, even repetitive if necessary, achieving satisfactory limb-salvage rates probably implies a multidisciplinary control of the presenting risk factors for wound healing as well.

Why a multidisciplinary team may represent a key factor for lowering the inferior limb loss rate in diabetic neuro-ischaemic wounds: application in a departmental institution.

UNLABELLED: INTRODUCTION/AIM OF THE STUDY: To assess the influence of a multidisciplinary approach on the limb salvage rates in the treatment of patients suffering from diabetic ischaemic inferior limb ulcers. MATERIALS & METHOD: From September 2001 until March 2008, a consecutive series of 183 limbs with diabetic ischaemic wounds in 163 patients were treated by combined multi-level angioplasties as the primary revascularization approach in an institutional diabetic programme (two departmental hospitals). The avoidance of limb loss was retrospectively analyzed before and after the year 2005, as a landmark for implementing a "multidisciplinary diabetic foot clinic" in the routine daily care. RESULTS: Initial technical success for endovascular revascularization was noted in 152 limbs (83%). The aggregate limb salvage proportions at 12, 24, 32, 60 and 66 months (+/- SEM) were: 87% (+/- 2.8), 80% (+/- 3.9), 77% (+/- 4.4) and thereafter 77% (+/- 4.4), respectively. A comparison between the limb salvage rates before and after initiating the multidisciplinary group showed a significant difference (p = 0.040, CI: 1.040-5.311, HR: 2.35, Chi square = 4.22) with better results in the latest interval, employing effective team activity. No statistical deviation was found regarding the technique itself for revascularization at the same intervals (p = 0.381). CONCLUSION: Our experience suggests that limb salvage for diabetic ischaemic wounds may be favourably influenced by a co-ordinated multidisciplinary group. Although appropriate revascularization is crucial for limb rescue, a pluralist control of the attending risk factors influencing wound healing might be of matchless importance as well.